NPIMap

Organization Active NPI

Gillette Optometric Clinic PC

  • Corneal and Contact Management Optometrist
  • Gillette, WY
National Provider Identifier
1891850707
Registry record updated Apr 13, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Corneal and Contact Management OptometristTaxonomy code 152WC0802X
License
142-T Issued in WY
Legal business name
GILLETTE OPTOMETRIC CLINIC PC
Practice address
609 4J CT
Gillette, WY 82716-4135
Phone
(307) 682-2020
Fax
(307) 682-5656
NPI assigned
Dec 22, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 13, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Roger L Jordan, O.D.NPI 1972537561
Title
President
Phone
(307) 682-2020

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 152W00000X 93-T WY
Corneal and Contact Management OptometristGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 152WC0802X 142-T WY Primary
Corneal and Contact Management OptometristGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 152WC0802X 288-T WY
Vision Therapy OptometristGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 152WV0400X 263-T WY

Addresses

Primary practice location

609 4J CT
Gillette, WY 82716-4135

Mailing address

609 4J CT
Gillette, WY 82716-4135
Phone (307) 682-2020

Other identifiers 8

IdentifierTypeStateIssuer
103952100MedicaidWY
1659399376OtherWYROBERT MILLS, OD
1972537561OtherWYROGER JORDAN, OD
1023035854OtherWYDANA MCDERMOTT, OD
103718800MedicaidWI
11504720MedicaidWY
11903420MedicaidWY
1265466320OtherWYJOSEPH MAYCOCK, OD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20060206000611 WY Part B Supplier - Clinic/Group Practice 3870507221 Receives reassigned benefits from 6 practitioners
Practice locations: Gillette, WY
O20100930017208 WY DME Supplier - Physician - Optometrist 3870507221 Practice locations: Gillette, WY

National Provider Directory

National Provider Directory

Locations

609 Four-J Ct
Gillette, WY 82716
Phone (307) 682-2020

Interoperability endpoints

  • Direct secure messaging: jmaycock@gilletteoptometricclinic.eyefinity-direct.com
  • Direct secure messaging: afischer@gilletteoptometricclinic.eyefinity-direct.com
  • Direct secure messaging: rjordan@gilletteoptometricclinic.eyefinity-direct.com
  • Direct secure messaging: myounger@gilletteoptometricclinic.eyefinity-direct.com
  • Direct secure messaging: jfischer@gilletteoptometricclinic.eyefinity-direct.com

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1166745600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1271116800000",
    "number": "1891850707",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "609 4J CT",
            "city": "GILLETTE",
            "state": "WY",
            "postal_code": "827164135",
            "telephone_number": "307-682-2020",
            "fax_number": "307-682-5656"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "609 4J CT",
            "city": "GILLETTE",
            "state": "WY",
            "postal_code": "827164135",
            "telephone_number": "307-682-2020",
            "fax_number": "307-682-5656"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GILLETTE OPTOMETRIC CLINIC PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-22",
        "last_updated": "2010-04-13",
        "status": "A",
        "authorized_official_last_name": "JORDAN",
        "authorized_official_first_name": "ROGER",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "307-682-2020",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "WY",
            "license": "93-T",
            "primary": false
        },
        {
            "code": "152WC0802X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Optometrist, Corneal and Contact Management",
            "state": "WY",
            "license": "142-T",
            "primary": true
        },
        {
            "code": "152WC0802X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Optometrist, Corneal and Contact Management",
            "state": "WY",
            "license": "288-T",
            "primary": false
        },
        {
            "code": "152WV0400X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Optometrist, Vision Therapy",
            "state": "WY",
            "license": "263-T",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103952100",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ROBERT MILLS, OD",
            "identifier": "1659399376",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ROGER JORDAN, OD",
            "identifier": "1972537561",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DANA MCDERMOTT, OD",
            "identifier": "1023035854",
            "state": "WY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103718800",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "11504720",
            "state": "WY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "11903420",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "JOSEPH MAYCOCK, OD",
            "identifier": "1265466320",
            "state": "WY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Gillette, WY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 13, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.